Donald Trump’s unexpected presidential victory has an emotional effect, good and bad, for many people, but for hundreds of thousands of North Carolina’s working poor the outcome will have a deeper and more direct impact: It will profoundly affect their health.
These are the people, estimated to number between 300,000 and 500,000, who would have benefited by an expansion of Medicaid under the Affordable Care Act. North Carolina, of course, is one of 19 mostly Republican-controlled states that have refused to expand the program to include low-income adults without dependent children. But the election of Democratic presidential nominee Hillary Clinton would have raised the pressure on North Carolina to expand Medicaid, or at least preserved the possibly that it could act should Democrats regain control of the General Assembly.
Now it may not matter which party controls North Carolina. President-elect Trump and the Republicans who lead Congress have resolved to “repeal and replace” the ACA. The changes likely will mean an end to federal pressure for Medicaid expansion in the holdout states. Under the worse-case scenario, it would also mean revoking Medicaid coverage from people in states that have expanded.
This bad turn has yet another in North Carolina. Republican leaders here are pushing to have the $14 billion Medicaid program privatized by turning it over to for-profit managed care companies and non-profit groups of providers. Republican lawmakers like the idea of contracting out the state and federal program that serves 1.7 million children and adults because the state can simply make a lump-sum allocation to providers and doesn’t have to cope with cost overruns. But this approach encourages providers to ration services and cut payments to doctors. Patient care becomes simply a cost and the provider has an incentive to keep costs low to increase profits.
To privatize Medicaid, North Carolina will need approval from the federal government, which pays about two-thirds of the program’s cost. A Hillary Clinton administration committed to preserving President Obama’s signature achievement, the ACA, likely would not grant approval to a state that refused to expand Medicaid. Now there will be no such leverage.
Thus in North Carolina, Trump’s election may create a double crisis. It is likely to close the prospect of up to 500,000 people getting health care insurance and open the possibility that those who do qualify will have less access to care and the care they can get will be of lower quality.
The impact of these changes will not be confined to the low-income uninsured or Medicaid recipients. The effect will be statewide. Already the state has forgone billions of dollars in federal money even as North Carolinians pay taxes that support Medicaid expansion in other states. Now it has lost the possibility of such funding in the future. Those dollars would have created jobs, boosted rural hospitals and helped hold down health care costs for all as more was spent on preventing illness and less was spent on very sick, uninsured people coming into hospital emergency rooms.
Republican leaders in North Carolina and Congress dismiss the dire effects of denying and privatizing Medicaid.
At the state level, they say Medicaid will become more efficient and perhaps even more effective. That has not been the experience of other states that have put this crucial public mission into private hands. Instead, there has been reduced care and increased fraud.
At the federal level, Republicans say Medicaid funds can be disbursed as block grants with fewer restrictions. They say this will allow states to put more money into care and less into administration, and it gives states the flexibility to tailor the program to their specific needs. What is actually likely to happen is that less restricted funds will be diverted into politically favored projects run by well-connected companies. Medicaid dollars will be siphoned into slush funds.
Perhaps the only hope now is that the ACA and Medicaid will withstand an assault by virtue of their size and importance. It was one thing to vote to repeal and replace Obamacare when Obama would certainly veto it. It will be another thing when Republicans in Congress and North Carolina have the power to actually take health care coverage and health care services away from people. Perhaps, when they see what is really at stake, that lives are at stake, they’ll think twice. That’s a thin hope, but it’s all millions of low-income people in North Carolina and beyond have now that Republicans have it all.